Improving the precision of depression diagnosis in general practice: a cluster-randomized trial

Abstract

Background Methods to enhance the accuracy of the depression diagnosis continues to be of relevance to clinicians. The primary aim of this study was to compare the diagnostic precision of two different diagnostic strategies using the Mini International Neuropsychiatric Interview (MINI) as a reference standard. A secondary aim was to evaluate accordance between depression severity found via MINI and mean Major Depression Inventory (MDI) sum-scores presented at referral. Methods This study was a two-armed, cluster-randomized superiority trial embedded in the Collabri trials investigating collaborative care in Danish general practices. GPs performing case-finding were instructed always to use MDI when suspecting depression. GPs performing usual clinical assessment were instructed to detect depression as they would normally do. According to guidelines, GPs would use MDI if they had a clinical suspicion, and patients responded positively to two or three core symptoms of depression. We compared the positive predictive value (PPV) in the two groups. Results Fifty-one GP clusters were randomized. In total, 244 participants were recruited in the case-finding group from a total of 19 GP clusters, and 256 participants were recruited in the usual clinical assessment group from a total of 19 GP clusters. The PPV of the GP diagnosis, when based on case-finding, was 0.83 (95% CI 0.78–0.88) and 0.93 (95% CI 0.89–0.96) when based on usual clinical assessment. The mean MDI sum-scores for each depression severity group indicated higher scores than suggested cut-offs. Conclusions In this trial, systematic use of MDI on clinical suspicion of depression did not improve the diagnostic precision compared with the usual clinical assessment of depression. Trial registration The trial was retrospectively registered on 07/02/2016 at ClinicalTrials.gov. No. NCT02678845.

Variation in Psychometric Testing in General Practice – A Nationwide Cohort Study

“…A recent Danish clinical study on the value of systematic psychometric testing, ie, no variation in use, did not find the diagnosis of depression to be more precise when based on psychometric testing compared with usual clinical assessment. 9 This finding was somewhat confirmed in this study, as we found no significant difference between groups with varying propensity for PT use for most of the investigated treatment outcomes. The finding of increased variation in the provided services has also been reported in other studies, with indications that some variation is non-negligible due to derived outcomes, such as the need for immediate identification and treatment of patients at risk of suicidal behavior after the loss of a loved one.…”

“…A recent clinical trial showed that systematic use of a depression-related PT did not increase the diagnostic precision compared with usual clinical assessment in Danish general practice. 9 Variation in health care and their influence on treatment outcomes are well documented. 10 , 11 A recent Danish study found an excess variation between Danish general practices in terms of the chronic care services provided, eg, talk therapy.…”

A comparison of the original major depression inventory with a modified version: A Danish validation study

“…3,4 Therefore, there is a need for accurate diagnostic tools. 5 The Danish clinical guidelines for general practitioners (GPs) recommend the use of the patient-reported outcome measure, the Major Depression Inventory (MDI) (Figure S1), to assist with identification and monitoring of depression severity in patients. 6 The MDI contains items that cover the spectrum of all ICD-10 and DSM IV symptoms.…”

“…Most patients with depression are identified and treated in general practice 3,4 . Therefore, there is a need for accurate diagnostic tools 5 . The Danish clinical guidelines for general practitioners (GPs) recommend the use of the patient‐reported outcome measure, the Major Depression Inventory (MDI) (Figure S1), to assist with identification and monitoring of depression severity in patients 6 .…”

“…Correlated error terms added between item pairs (2, 3),(4,5), and(7,8). Abbreviations: CI, confidence interval; CFI, comparative fit index; df, degrees of freedom; MDI, Major Depression Inventory; mMDI, modified Major Depression Inventory; RMSEA, root mean square error of approximation; TLI, Tucker-Lewis Index.…”